Confidential & Protected

New Client Intake Form

Please complete this form as fully as possible. All information you provide is confidential. If you are unsure of an answer, write "Unknown." A member of our legal team will contact you shortly after reviewing your submission.

Your Contact Information

Full Name *

Phone Number *

Email Address

Best Way to Reach You *

Case Type & Location

What kind of legal matter are you contacting us about? *Choose the one that best fits

County where this happened *

City where this happened *

Personal Injury Details

Date of Incident *

Approximate Time of Incident

Type of Accident *

Your role in the accident *

Were you injured? *

Did you receive medical treatment?

What body parts were injured?List all that apply

Where did you receive treatment?Hospital name, clinic, doctor's office

Was there another vehicle involved?

Were there witnesses?

Was a police report filed?

Do you have auto insurance?

Insurance company nameYour insurance or the other driver's

Have you already spoken to or hired another attorney?

Tell us what happened in your own words *

Criminal Defense Details

Date of Arrest or Incident

What are the charges? *As listed on your paperwork

Is it a felony or misdemeanor?Check your paperwork if unsure

Are you currently in custody?

Case NumberOn your court papers, if available

Next Court DateIf you have one scheduled

Which court / jurisdiction?

Are you a U.S. Citizen? *Important — charges can affect immigration status

Do you have prior criminal history? *

Prior criminal history detailsIf yes, briefly describe

Have you already spoken to or hired another attorney?

Tell us what happened in your own words *

CPS / Juvenile Dependency Details

Are your children currently removed from your home? *

How many children are involved? *

Ages of children *

When did CPS / DCFS first get involved?Approximate is fine

Reason given by CPS / DCFS *

Name of CPS / DCFS Social WorkerIf you have it

Social Worker's Phone or AgencyIf known

Next court dateIf there is one scheduled

Is there already an open court case?

Which court?If you know

Have you been asked to complete a case plan?

Do you have any criminal history?

Criminal history detailsIf yes, briefly describe

Tell us your situation in your own words *

Final Questions

Brief description of what happened *In your own words — the more detail the better

How did you hear about us?

Is there anything else you would like us to know?Optional

🔒 For Staff Only — Do Not Share With Client

Case Priority

Assigned To

Follow-Up Date

Was the client quoted a fee?

All information submitted through this form is strictly confidential and protected by attorney-client privilege.
Submission of this form does not establish an attorney-client relationship.